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Gnech M, 't Hoen L, Zachou A, Bogaert G, Castagnetti M, O'Kelly F, Quaedackers J, Rawashdeh YF, Silay MS, Kennedy U, Skott M, van Uitert A, Yuan Y, Radmayr C, Burgu B. Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children. Eur Urol 2024; 85:433-442. [PMID: 38182493 DOI: 10.1016/j.eururo.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND AND OBJECTIVE The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines. METHODS A structured literature review was performed for all relevant publications published from the last update up to March 2022. KEY FINDINGS AND LIMITATIONS The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates. CONCLUSIONS AND CLINICAL IMPLICATIONS This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children. ADVANCING PRACTICE For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution. PATIENT SUMMARY We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.
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Affiliation(s)
- Michele Gnech
- Department of Paediatric Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Lisette 't Hoen
- Department of Pediatric Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alexandra Zachou
- Department of HIV and Sexual Health, Chelsea & Westminster Hospital, London, UK
| | - Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Marco Castagnetti
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital Dublin & University College Dublin, Ireland
| | - Josine Quaedackers
- Department of Urology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yazan F Rawashdeh
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Mesrur Selcuk Silay
- Division of Pediatric Urology, Department of Urology, Biruni University, Istanbul, Turkey
| | - Uchenna Kennedy
- Department of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Skott
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Allon van Uitert
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yuhong Yuan
- Department of Medicine, London Health Science Centre, London, Ontario, Canada, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
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De Palma D, Botta F. Conflicting views of physicians and surgeons concerning paediatric urinary tract infection: a comparative review. May nuclear medicine provide an answer? Reply to Hewitt et al. Pediatr Radiol 2024; 54:655-656. [PMID: 38300286 DOI: 10.1007/s00247-024-05870-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/02/2024]
Affiliation(s)
- Diego De Palma
- Nuclear Medicine Unit, ASST-Settelaghi, Via Lazio 51, 21100, Varese, Italy.
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Pakkasjärvi N, Belov S, Jahnukainen T, Kivisaari R, Taskinen S. Stratifying Antenatal Hydronephrosis: Predicting High-Grade VUR Using Ultrasound and Scintigraphy. Diagnostics (Basel) 2024; 14:384. [PMID: 38396423 PMCID: PMC10888138 DOI: 10.3390/diagnostics14040384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Antenatal hydronephrosis (AHN), detected in approximately one percent of prenatal ultrasounds, is caused by vesicoureteral reflux (VUR) in 15-21% of cases, a condition with significant risks such as urinary tract infections and renal scarring. Our study addresses the diagnostic challenges of VUR in AHN. Utilizing renal ultrasonography and scintigraphy, we developed a novel scoring system that accurately predicts high-grade VUR, optimizing diagnostic precision while minimizing the need for more invasive methods like voiding cystourethrogram (VCUG); (2) Methods: This retrospective study re-analyzed renal ultrasonography, scintigraphy, and VCUG images from infants admitted between 2003 and 2013, excluding cases with complex urinary anomalies; (3) Results: Our analysis included 124 patients (75% male), of whom 11% had high-grade VUR. The multivariate analysis identified visible ureter, reduced renal length, and decreased differential renal function (DRF) as primary predictors. Consequently, we established a three-tier risk score, classifying patients into low, intermediate, and high-risk groups for high-grade VUR, with corresponding prevalences of 2.3%, 22.2%, and 75.0%. The scoring system demonstrated 86% sensitivity and 79% specificity; (4) Conclusions: Our scoring system, focusing on objective parameters of the visible ureter, renal length, and DRF, effectively identifies high-grade VUR in AHN patients. This method enhances diagnostics in ANH by reducing reliance on VCUG and facilitating more tailored and less invasive patient care.
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Affiliation(s)
- Niklas Pakkasjärvi
- Department of Pediatric Surgery, Helsinki University Hospital, 000290 Helsinki, Finland; (S.B.); (S.T.)
| | - Sofia Belov
- Department of Pediatric Surgery, Helsinki University Hospital, 000290 Helsinki, Finland; (S.B.); (S.T.)
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Helsinki University Hospital, University of Helsinki, 000290 Helsinki, Finland;
| | - Reetta Kivisaari
- Department of Pediatric Radiology, Helsinki University Hospital, 000290 Helsinki, Finland;
| | - Seppo Taskinen
- Department of Pediatric Surgery, Helsinki University Hospital, 000290 Helsinki, Finland; (S.B.); (S.T.)
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Pakkasjärvi N, Ripatti L, Läckgren G, Krishnan N, Anand S. PIC cystography in occult vesicoureteral reflux: A systematic review highlighting its utility in children with recurrent urinary tract infections and normal VCUG. J Pediatr Urol 2023; 19:804-811. [PMID: 37633825 DOI: 10.1016/j.jpurol.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/30/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) affects 1-2% of children, predisposing them to pyelonephritis, renal scarring, and reflux nephropathy. Treatment aims to prevent febrile urinary tract infections (f-UTI) and long-term sequelae. While guidelines differ, the current consensus proposes individual risk-stratification and subsequent management strategies. Here, we systematically analyzed the current literature on Positional Instillation of Contrast Cystography (PIC) for individualized diagnostics in patients with recurrent f-UTIs. OBJECTIVE We present a comprehensive qualitative and quantitative synthesis. Outcomes were: 1. the ability of PIC to predict VUR in patients with negative voiding cystographies (VCUG), 2. the ability of PIC to predict occult contralateral VUR, 3. the correlation of occult VUR in PIC with dimercaptosuccinic acid (DMSA) scan findings, and 4. the incidence of postoperative f-UTI in children treated for occult VUR picked up on PIC. STUDY DESIGN We conducted a systematic review following the PRISMA guidelines, applying the following inclusion criteria: Children with occult VUR in PIC with negative VCUG. RESULTS We included nine studies with 496 symptomatic patients with a mean age of 6.8 years, published between 2003 and 2021. PIC detected VUR in 73% of patients. Out of them, 81% had low-grade and 19% high-grade VUR. Occult contralateral VUR was present in 41% children. The presence of renal scars on DMSA scan was 1.39 times more likely with occult VUR on PIC. 85% of patients did not experience recurrent f-UTIs after PIC and subsequent treatment. DISCUSSION PIC can detect occult VUR in patients with recurrent f-UTIs in whom VCUG is negative. However, we recommend a cautious approach in the use of PIC in clinical practice until further prospective studies confirm the validity of our outcome measures. CONCLUSION Identification, risk stratification, and prompt action are central in managing VUR. PIC can be helpful in identifying VUR in patients with recurrent f-UTI.
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Affiliation(s)
- Niklas Pakkasjärvi
- Department of Pediatric Surgery, Turku University Hospital, Turku 20521, Finland; Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Liisi Ripatti
- Department of Pediatric Surgery, Turku University Hospital, Turku 20521, Finland
| | - Göran Läckgren
- Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Nellai Krishnan
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sachit Anand
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India.
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Karakaya D, Güngör T, Cakıcı EK, Yazılıtaş F, Celikkaya E, Bulbul M. Determining the effectiveness of the immature granulocyte percentage and systemic immune-inflammation index in predicting acute pyelonephritis. Postgrad Med 2023; 135:155-160. [PMID: 36472407 DOI: 10.1080/00325481.2022.2152970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM The most serious form of urinary tract infection (UTI) is acute pyelonephritis (APN), which can result in bacteremia and renal scarring. This study aims to show the roles that the systemic immune-inflammation index (SII) and the immature granulocyte (IG) percentage play in predicting APN in pediatric patients by comparing them with traditional infection markers. By illustrating a significant relationship between APN, the IG percentage, and the SII, the study's contributions to the differential diagnosis of UTI can promote a rapid and appropriate treatment of APN. MATERIAL AND METHODS The present study included 522 pediatric patients. The patients were divided into two groups: (I) an APN group (n = 236) and (II) a lower UTI group (n = 286). RESULTS The mean age of the sample was 5.05 ± 4.7 years. According to the most appropriate cutoff values, the findings showed that among all the parameters, C-reactive protein (CRP) and the IG percentage had the highest sensitivities, specificities, and predictive values for predicting APN. CONCLUSION This study emphasizes the support features of the IG percentage and the SII in the diagnosis of APN in pediatric patients, a topic that has recently attracted attention. The findings indicated that among all of the parameters behind CRP, the IG percentage and the SII had the highest sensitivities, specificities, and predictive values for forecasting APN. It is worth noting that these methods can be applied without additional costs or burdens to the patient.
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Affiliation(s)
- Deniz Karakaya
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Tülin Güngör
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Evrim Kargın Cakıcı
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Fatma Yazılıtaş
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Evra Celikkaya
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Mehmet Bulbul
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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SNMMI procedure standard/EANM practice guideline on pediatric [99mTc]Tc-DMSA renal cortical scintigraphy: an update. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00484-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AbstractThe Society of Nuclear Medicine and Molecular Imaging (SNMMI), founded in 1954, is an international scientific and professional organization with a purpose to promote the science, technology, and practical application of nuclear medicine. The European Association of Nuclear Medicine (EANM), founded in 1985, is a nonprofit professional medical association with a purpose to facilitate international communication among individuals in nuclear medicine pursuing clinical and academic excellence. Members of the SNMMI and EANM are physicians, technologists, and scientists who specialize in the research and practice of nuclear medicine. The SNMMI and EANM will periodically publish new guidelines for nuclear medicine practice to further advance the science of nuclear medicine and improve patient care. Existing standards/guidelines will be reviewed for revision or renewal, as appropriate. Each standard/guideline, representing a policy statement by the SNMMI/EANM, has undergone a thorough review, and represents an expert consensus. The SNMMI and EANM recognize that the safe and effective use of diagnostic nuclear medicine imaging requires specific training and skills, as described in each document. These standards/guidelines are educational resources designed to assist practitioners in providing appropriate nuclear medicine care for patients. They are consensus documents, and are not mandatory provisions or requirements of practice. They are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the SNMMI and the EANM cautions against the use of these standards/guidelines in litigation procedures that call into question the clinical decisions of a practitioner. The ultimate judgment regarding the appropriateness and propriety of any specific procedure or course of action must be made by medical professionals, taking into account the unique context of each case. Thus, there is no implication that action differing from what is detailed in these standards/guidelines, on its own, is below the standard of care. On the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the standards/guidelines when, based on the reasonable judgment of the practitioner, such course of action is warranted based on the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the standards/guidelines. Practicing medicine involves not only the science, but also the art of dealing with the prevention, detection, diagnosis, and treatment of disease. The variety and complexity of human conditions make it impossible for general guidelines to consistently allow for an accurate diagnosis to be reached or a specific treatment response to be predicted. Therefore, it should be recognized that adhering to these standards/guidelines does not ensure a successful outcome. All that should be expected is that a practitioner follows a reasonable course of action based on their level of training, the current landscape of knowledge, the resources at their disposal, and the needs/context of the particular patient being treated. The purpose of this document is to provide nuclear medicine physicians, radiologists, and other clinicians with guidelines for the recommendation, performance and interpretation of 99mTc-dimercaptosuccinic acid renal cortical scintigraphy ([99mTc] Tc-DMSA scintigraphy) in pediatric patients. These recommendations represent the expert opinions of experienced leaders in this field, and these recommendations are not all supported by a high level of evidence. Further studies are required to have evidence-based recommendations for the application of [99mTc] Tc-DMSA renal cortical scintigraphy in pediatrics. This guideline summarizes the views of the SNMMI Renal Cortical Scintigraphy in Children Working Group and the EANM Pediatrics Committee. It reflects recommendations for which the SNMMI and EANM cannot be held responsible. The recommendations should be taken into context of good practice of nuclear medicine and do not substitute for national and international legal or regulatory provisions.
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Bar-Sever Z, Shammas A, Gheisari F, Vali R. Pediatric Nephro-Urology: Overview and Updates in Diuretic Renal Scans and Renal Cortical Scintigraphy. Semin Nucl Med 2022; 52:419-431. [PMID: 35031115 DOI: 10.1053/j.semnuclmed.2021.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Abstract
Nuclear medicine offers several diagnostic scans for the evaluation of congenital and acquired conditions of the kidneys and urinary track in children. Tc-99m-MAG 3 diuretic renal scans are most commonly used in the evaluation and follow up of urinary track dilatations. They provide functional information on the differential renal function and on drainage quality which is allows distinction between obstructed and non-obstructed kidneys and the need for surgical correction vs conservative management in kidneys with impaired drainage. Standardized imaging and processing protocols are essential for correct interpretation and for meaningful comparisons between follow up scans. Different approaches and conceptions led to some contradicting recommendations between SNMMI and EANM guidelines on diuretic renography in children which caused confusion and to the emergence of self-made institutional protocols. In Late 2018 the two societies published joint procedural guidelines on diuretic renography in infants and children which hopefully will end the confusion. Tc-99m DMSA scans provide important information about the function of the renal cortex allowing detection of acute pyelonephritis, renal scars dysplasia and ectopy as well as accurate determination of the differential renal function. They are commonly used in the evaluation of children with urinary tract infections and affect clinical management. A standardized imaging and processing protocol improves the diagnostic accuracy of these studies. SPECT or pinhole images should be a routine part of the imaging protocol. This is one of the recommendations in the new EANM and SNMMI procedural guidelines for renal cortical scintigraphy in children available online on the SNMMI website and is under publication. This article provides an overview on the clinical role of diuretic renography and cortical scintigraphy in children and describes the imaging protocols focusing on the new recommendations in the procedural guidelines.
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Affiliation(s)
- Zvi Bar-Sever
- Department of Nuclear Medicine, Schneider Children's Medical Center, Petach Tikva, Tel-Aviv University, Israel.
| | - Amer Shammas
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Farshid Gheisari
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Reza Vali
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
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Breinbjerg A, Jørgensen CS, Frøkiær J, Tullus K, Kamperis K, Rittig S. Risk factors for kidney scarring and vesicoureteral reflux in 421 children after their first acute pyelonephritis, and appraisal of international guidelines. Pediatr Nephrol 2021; 36:2777-2787. [PMID: 33754234 DOI: 10.1007/s00467-021-05042-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/05/2021] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute pyelonephritis (AP) is a common bacterial infection in childhood. Follow-up guidelines on these children are controversial. This study aimed to identify risk factors for kidney scarring and vesicoureteral reflux (VUR). Furthermore, international follow-up guidelines were used for simulation to evaluate sensitivity and specificity. METHODS Urinary culture-confirmed first-time AP patients (aged 0-14 years) were enrolled (n = 421) from review of patient charts. All underwent kidney ultrasound (US) and a technetium-99m-dimercaptosuccinic acid (DMSA) scan or technetium-99m-mercaptoacetyltriglycine scinti-renography (MAG3) at 4-6 months of follow-up. The international guidelines used for simulation were from the National Institute of Health UK (NICE), the American Association of Paediatrics (AAP) and the Swedish Paediatric Society (SPS). RESULTS 17.8% presented with an abnormal DMSA/MAG3 at follow-up, 7.1% were diagnosed with VUR grades III-V and 4.7% were admitted for surgery. Non-Escherichia coli infections, abnormal kidney US, elevated creatinine and delayed response to treatment (>48 h) were risk factors for abnormal DMSA findings and VUR grades III-V. NICE and SPS guidelines showed best sensitivity in diagnosing VUR grades III-V (75%) compared with AAP (56%). CONCLUSIONS Risk factors are helpful in identifying the children in need of further investigations and minimizing invasive work-up for the rest. International guidelines on follow-up detect a varying number of children with kidney damage and/or significant VUR. Future work must focus on identifying more specific risk factors, better imaging, or specific biomarkers, to enhance sensitivity and specificity in detecting the children at high risk for developing recurrent infections and/or nephropathy.
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Affiliation(s)
- Anders Breinbjerg
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | | | - Jørgen Frøkiær
- Department of Clinical Medicine, Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Konstantinos Kamperis
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Rittig
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Hewitt IK, Montini G. Childhood urinary tract infections: A Swedish perspective and comparison with other published guidelines. Acta Paediatr 2021; 110:1708-1710. [PMID: 33738791 DOI: 10.1111/apa.15779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Ian K. Hewitt
- Department of Pediatric Nephrology Perth Children's Hospital Perth WA Australia
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit Fondazione Ca’ Granda IRCCSPoliclinico di Milano Milano Italy
- Giuliana and Bernardo Caprotti Chair of Pediatrics Department of Clinical Sciences and Community Health University of Milano Milano Italy
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Bastos JM, Rondon AV, Machado MG, Zerati M, Nascimento RLP, Lima SVC, Calado ADA, Barroso U. Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice. Int Braz J Urol 2020; 46:523-537. [PMID: 32167732 PMCID: PMC7239285 DOI: 10.1590/s1677-5538.ibju.2019.0401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction Vesicoureteral Reflux (VUR) is characterized by a retrograde flow of urine from the bladder into the ureters and kidneys. It is one of the most common urinary tract anomalies and the major cause of urinary tract infection (UTI) in the first years of life. If not properly diagnosed and treated can lead to recurrent UTI, renal scar and, in severe cases, to end stage renal disease. Despite recent advances in scientific and technological knowledge, evaluation and treatment of VUR is still controversial and there is still considerable heterogeneity in evaluation methods and therapeutic approaches. The aim of the present consensus is to give a practical orientation on how to evaluate and treat VUR. Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Vesicoureteral Reflux evaluation and treatment and elaborated a draft of the document. On November 2017 the panel met to review, discuss and write a consensus document. Results and Discussion Vesicoureteral Reflux is a common and challenging problem in children. Children presenting with Vesicoureteral Reflux require careful evaluation and treatment to avoid future urinary tract infections and kidney scars. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.
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Affiliation(s)
- José Murillo Bastos
- Universidade Federal de Juiz de Fora -UFJF, Juiz de Fora, MG, Brasil.,Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e Saúde de Juiz de Fora - HMTJ-SUPREMA, Juiz de Fora, MG, Brasil
| | - Atila Victal Rondon
- Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil.,Hospital Federal Cardoso Fontes - HFCF, Rio de Janeiro, RJ, Brasil
| | | | - Miguel Zerati
- Instituto de Urologia e Nefrologia de São José do Rio Preto - IUN, S J do Rio Preto, SP, Brasil
| | | | | | - Adriano de Almeida Calado
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo - HCFMRP-USP, Ribeirão Preto, SP, Brasil
| | - Ubirajara Barroso
- Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil.,Escola Bahiana de Medicina - BAHIANA, Salvador, BA, Brasil
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Zhu H, Chen M, Luo H, Pan Y, Zheng W, Yang Y. Semiquantitative analysis of power doppler ultrasonography versus Tc-99m DMSA scintigraphy in diagnostic and severity assessment of acute childhood pyelonephritis. Transl Pediatr 2020; 9:487-495. [PMID: 32953546 PMCID: PMC7475307 DOI: 10.21037/tp-20-59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND This study aimed to compare the diagnostic and predictive value of power Doppler ultrasonography (PDU) with Tc-99m dimercaptosuccinic acid (DMSA) renal scintigraphy in pediatric acute pyelonephritis (APN) using a semiquantitative analysis system. METHODS A total of 92 children and infants (184 kidneys) were hospitalized with possible APN. All children were examined by PDU and DMSA scintigraphy within 72 hours of admission. An empiric 9-point semiquantitative analysis system was used to sort kidneys into four grades (grade 0-III). Patients with several episodes of APN and congenital structural anomalies were excluded. RESULTS Of 184 kidneys, we found 68 abnormal (grade I-III) and 116 normal (Grade 0) with DMSA scintigraphy, and 84 abnormal and 100 normal with PDU. In all, 23 kidneys were shown to be diseased by PDU but normal on DMSA scintigraphy while 7 kidneys showed the opposite trend. The sensitivity and specificity of PDU for diagnosing APN was 89.7% and 80.2%, respectively (P<0.05). In children older than 6 months, the sensitivity was higher (92%, P<0.05) than that in children younger than 6 months (87%, P<0.05). A moderate agreement (41%, P<0.05) on grade was found between the two methods. CONCLUSIONS With the help of a semiquantitative analysis system, PDU can obviate the use of DMSA scintigraphy in children older than 6 months for APN diagnosis.
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Affiliation(s)
- Hui Zhu
- Department of Ultrasound, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Minguang Chen
- Department of Pediatrics, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hongxia Luo
- Department of Ultrasound, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yin Pan
- Department of Ultrasound, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenjie Zheng
- Department of Pediatrics, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan Yang
- Department of Ultrasound, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Kawai S, Nakai H, Kanai T, Tanabe K, Hyuga T, Nakamura S, Betsui H, Aoyagi J, Saito T, Ito T, Odaka J, Furukawa R, Aihara T. Prevention of recurrent febrile urinary tract infection in infants: Ultrasonography-oriented approach is more practical than a top-down approach. Pediatr Int 2019; 61:1007-1014. [PMID: 31298773 DOI: 10.1111/ped.13970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 03/29/2019] [Accepted: 05/16/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND We previously reported that the top-down approach (TDA) for infants with febrile urinary tract infections (fUTI) could prevent recurrent fUTI (r-fUTI) but produced a high number of false-positives on acute-phase 99m Tc dimercaptosuccinic acid (DMSA) renal scintigraphy. Therefore we compared the ultrasonography-oriented approach (USOA) with TDA from the viewpoint of prevention of r-fUTI. METHODS The TDA was applied between July 2010 and February 2014 and the USOA was applied between March 2014 and April 2017 in infants with first fUTI. In the USOA group, voiding cystourethrography (VCUG) was performed in the case of abnormality on acute-phase renal bladder ultrasonography (RBUS) or on chronic- phase DMSA, which were performed in all cases. The frequency of r-fUTI was compared between the TDA group and USOA group retrospectively. RESULTS Seventy-four infants (52 male) and 79 infants (60 male) received TDA or USOA, respectively. No significant differences were found between the TDA and USOA groups in male : female ratio, age in months at initial onset of fUTI, observation period, or number of cases of r-fUTI (TDA group, n = 4; USOA group, n = 5). Seventy-four DMSA scintigraphy and 25 VCUG were carried out in the USOA group, and 111 DMSA scintigraphy and 34 VCUG in the TDA group. CONCLUSIONS Both USOA and TDA were valid for prevention of r-fUTI, but USOA was superior to TDA with regard to the reduced number of patients undergoing VCUG and DMSA.
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Affiliation(s)
- Shina Kawai
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Hideo Nakai
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Takahiro Kanai
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Kazuya Tanabe
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Taiju Hyuga
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Shigeru Nakamura
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Hiroyuki Betsui
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Jun Aoyagi
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Takashi Saito
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Takane Ito
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Jun Odaka
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Rieko Furukawa
- Department of Pediatric Radiology, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Toshinori Aihara
- Department of Pediatric Radiology, Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
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Balestracci A, Montecuco M, Serviddio C, Figueredo LD, Montiel V, Torres Perez C, Puyol I, Capone MA. Role of Late DMSA Renal Scan in Detecting High-Grade Vesicoureteral Reflux. Indian J Pediatr 2019; 86:784-789. [PMID: 30859438 DOI: 10.1007/s12098-019-02917-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/18/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the performance of late dimercaptosuccinic acid (DMSA) renal scans in identifying high-grade (III-V) vesicoureteral reflux (VUR) in children aged over 3 y with a febrile urinary tract infection (fUTI) history that has not been timely investigated. METHODS In this retrospective study of diagnostic accuracy, the clinical records of children aged between 3 and 18 y with fUTI history evaluated consecutively at Nephrology Unit of Hospital General de Niños Pedro de Elizalde, Argentina between 2006 and 2016 were reviewed. Patients with previously diagnosed renal or urinary tract abnormalities or who underwent previous postnatal genitourinary imaging were excluded. Only those assessed by renal and bladder ultrasound (RBUS), voiding cystourethrogram (VCUG) and late 6-mo DMSA scan were analyzed. The ability of the scintigraphy in identifying high-grade VUR was determined by comparing its findings with those of VCUG. RESULTS In 122 children (median age 5.37 y, 88.5% girls) RBUS was abnormal in 53 (43.4%) and 58 (47.5%) had VUR (30 of high-grade). Abnormal DMSA scan findings (70 patients, 57.4%) were associated with all grade (p = 0.00001) and with high-grade VUR (p = 0.00001). Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of late DMSA scans for all grades VUR were 93.1%, 75%, 92.3% and 77.1%, respectively. Only 4 patients with low-grade VUR had normal scans. For high-grade VUR, sensitivity and NPV reached 100%. CONCLUSIONS In older children, the normal late DMSA scan predicted the absence of high-grade VUR, obviating the need for a VCUG. This approach could be a possible strategy for children not studied at acute infection time.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Micaela Montecuco
- Department of Pediatrics, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Argentina
| | - Carla Serviddio
- Department of Pediatrics, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Argentina
| | - Lourdes Domínguez Figueredo
- Department of Pediatrics, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Argentina
| | - Virginia Montiel
- Department of Pediatrics, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Argentina
| | - Cecilia Torres Perez
- Department of Pediatrics, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Argentina
| | - Iris Puyol
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marina A Capone
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
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Pokrajac D, Sefic-Pasic I, Begic A. Vesicoureteral Reflux and Renal Scarring in Infants After the First Febrile Urinary Tract Infection. Med Arch 2019; 72:272-275. [PMID: 30514993 PMCID: PMC6195033 DOI: 10.5455/medarh.2018.72.272-275] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction The objective of this research was to determine whether vesicoureteral reflux(VUR) was associated with evolution to renal scarring (RS) following a febrile urinary tract infection (UTI) in infants. Materials and methods Our research included 100 infants, ages up to 1 year with a first febrile UTI. The diagnostic was based on results of: laboratory findings, ultrasonography (USG), voiding cystourethrography (VCUG) and initial and control renal scintigraphy (DMSA renal scan) withtechnetium99mTcsuccimer (dimercaptosuccinic acid), to assess the acute pyelonephritis (APN), VUR and RS. Results APN was proven with DMSA renal scan in 66 (66%) infants. Twenty-two infants (33.3%) had VUR in-group of patients with APN. On the control DMSA scan, performed 6 months after the first DMSA, the presence of RS was found in 18 (27.27%) infants. In infants with renal scars VUR were discovered in 9 of them (50%). Conclusions The pathogenesis of RS after febrile UTI in young children is multifactorial. Children with VUR have an increased risk for APN and RS. However, VUR is not the only precondition for RS. Creating a renal scarring cannot be imagined without the inflammatory process of the upper urinary system. Therefore, early detection and treatment of febrile UTIs in children and identify children at risk for RS are of primary importance.
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Affiliation(s)
- Danka Pokrajac
- Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Irmina Sefic-Pasic
- Clinic of Radiology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amela Begic
- Clinic for Nuclear Medicine, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Visuri S, Jahnukainen T, Kivisaari R, Taskinen S. Reduced differential renal function in scintigraphy predicted high-grade vesicoureteral reflux in children with antenatal hydronephrosiss. Acta Paediatr 2019; 108:751-756. [PMID: 30113092 DOI: 10.1111/apa.14536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/06/2018] [Accepted: 08/13/2018] [Indexed: 01/26/2023]
Abstract
AIM A top-down approach is widely used for detecting vesicoureteral reflux (VUR) in children with febrile urinary tract infections. We evaluated the diagnostic value of renal scintigraphy in predicting VUR in children with antenatal hydronephrosis (AHN). METHODS The voiding cystourethrogram (VCUG) and renal scintigraphy results of 125 AHN patients (76% male) admitted to the Children's Hospital of Helsinki University, Finland, from 2003 to 2013 were analysed. Of those, 94 had nonrefluxing hydronephrosis, nine had low-grade VUR and 22 had high-grade VUR. RESULTS Scintigraphy was performed at a median age of 1.4 (0.8-15.6) months. In patients with high-grade VUR, the differential renal function (DRF) of the worse kidney was significantly lower than in patients without VUR, with a median of 35% and interquartile range (IQR) of 20-45 versus 47% (IQR: 44-49), (p < 0.001). There was no difference between patients with low-grade VUR and patients without VUR (p = 0.181). DRFs below 44% showed a sensitivity of 73% and specificity of 79% and predicted significantly high-grade VUR (odds ratio 9.82, 95% confidence interval 3.44-28.05, p < 0.001) in the univariate analysis. CONCLUSION A DRF below 44% predicted high-grade VUR in patients with AHN and supported the decision to perform VCUG.
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Affiliation(s)
- Sofia Visuri
- University of Helsinki; Helsinki Finland
- Department of Pediatric Surgery; Uppsala University Children's Hospital; Uppsala Sweden
- Department of Pediatric Surgery; Helsinki University Hospital; Helsinki Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation; Helsinki University Hospital and University of Helsinki; Helsinki Finland
| | - Reetta Kivisaari
- Department of Pediatric Radiology; Helsinki University Hospital; Helsinki Finland
| | - Seppo Taskinen
- Department of Pediatric Surgery; Helsinki University Hospital; Helsinki Finland
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17
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Johnin K, Kobayashi K, Tsuru T, Yoshida T, Kageyama S, Kawauchi A. Pediatric voiding cystourethrography: An essential examination for urologists but a terrible experience for children. Int J Urol 2018; 26:160-171. [PMID: 30569659 DOI: 10.1111/iju.13881] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 11/14/2018] [Indexed: 12/24/2022]
Abstract
Voiding cystourethrography is the most important fluoroscopic examination in pediatric urology for the investigation of lower urogenital tract diseases, such as vesicoureteral reflux or urethral stricture. However, this invasive procedure imposes a significant burden on children and their parents, and recently there has been a paradigm shift in the diagnosis and treatment of vesicoureteral reflux. In the 2011 revision, the American Academy of Pediatrics guidelines on urinary tract infection recommended abandoning routine voiding cystourethrography after the first febrile urinary tract infection. In 2014, the randomized intervention for children with vesicoureteral reflux study recommended discontinuation of routine continuous antibiotic prophylaxis for vesicoureteral reflux. The time is now ripe to radically reconsider indications for voiding cystourethrography and the procedure itself.
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Affiliation(s)
- Kazuyoshi Johnin
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Kenichi Kobayashi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Teruhiko Tsuru
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tetsuya Yoshida
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Susumu Kageyama
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akihiro Kawauchi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
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19
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Beetz R. Pyelonephritis und Urosepsis. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Hewitt IK, Montini G. Re-evaluating the use of ultrasound to investigate first febrile urinary tract infections in childhood. Acta Paediatr 2017; 106:1727-1728. [PMID: 28836698 DOI: 10.1111/apa.14007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ian K. Hewitt
- Pediatric Nephrology; Princess Margaret Hospital for Children; Perth WA Australia
| | - Giovanni Montini
- Pediatric Nephrology and Dialysis Unit; Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico; Milano Italy
- Department of Community Health and Clinical Sciences; University of Milan; Milano Italy
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21
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Yield of Imaging Performed as per Indian Society of Pediatric Nephrology Guidelines in Children with Urinary Tract Infection. Indian Pediatr 2017; 54:749-751. [PMID: 28984254 DOI: 10.1007/s13312-017-1168-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess yield of imaging performed as per Indian Society of Pediatric Nephrology (ISPN) urinary tract infection (UTI) guideline. METHODS Ultrasonography (USG), voiding cystourethrography (VCUG) and dimercaptosuccinic-acid (DMSA) scintigraphy were performed in 183 children (age 0-5y) with first episode (age 0-1y) of UTI or recurrent (age <5y) UTI, as per ISPN recommendations. RESULTS Significant abnormalities were detected in 110 (63%), with vesicoureteric reflux (VUR) grades 3-5 in 31% and renal scars in 43%. Combined USG and DMSA had a negative predictive value of 94% for significant VUR. Conclusion ISPN guideline resulted in a high yield of detection of significant abnormalities.
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22
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Biassoni L, Easty M. Paediatric nuclear medicine imaging. Br Med Bull 2017; 123:127-148. [PMID: 28910997 DOI: 10.1093/bmb/ldx025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nuclear medicine imaging explores tissue viability and function by using radiotracers that are taken up at cellular level with different mechanism. This imaging technique can also be used to assess blood flow and transit through tubular organs. Nuclear medicine imaging has been used in paediatrics for decades and this field is continuously evolving. SOURCES OF DATA The data presented comes from clinical experience and some milestone papers on the subject. AREAS OF AGREEMENT Nuclear medicine imaging is well-established in paediatric nephro-urology in the context of urinary tract infection, ante-natally diagnosed hydronephrosis and other congenital renal anomalies. Also, in paediatric oncology, I-123-meta-iodobenzyl-guanidine has a key role in the management of children with neuroblastic tumours. Bone scintigraphy is still highly valuable to localize the source of symptoms in children and adolescents with bone pain when other imaging techniques have failed. Thyroid scintigraphy in neonates with congenital hypothyroidism is the most accurate imaging technique to confirm the presence of ectopic functioning thyroid tissue. AREAS OF CONTROVERSY Radionuclide transit studies of the gastro-intestinal tract are potentially useful in suspected gastroparesis or small bowel or colonic dysmotility. However, until now a standardized protocol and a validated normal range have not been agreed, and more work is necessary. Research is ongoing on whether magnetic resonance imaging (MRI), with its great advantage of great anatomical detail and no ionizing radiations, can replace nuclear medicine imaging in some clinical context. On the other hand, access to MRI is often difficult in many district general hospitals and general anaesthesia is frequently required, thus adding to the complexity of the examination. GROWING POINTS Patients with bone pain and no cause for it demonstrated on MRI can benefit from bone scintigraphy with single photon emission tomography and low-dose computed tomography. This technique can identify areas of mechanical stress at cortical bone level, difficult to demonstrate on MRI, which can act as pain generators. Positron emission tomography (PET) is being tested in the staging, response assessment and at the end of treatment of several paediatric malignancies. PET is becoming more widely utilized in neurology in the pre-surgical assessment of some children with drug resistant epilepsy. AREAS TIMELY FOR DEVELOPING RESEARCH The use of PET/MRI scanners is very attractive as it combines benefits of MR imaging with the assessment of cellular viability and metabolism with PET in one examination. This imaging technique will allow important research on tumour in-vivo metabolism (possible applications include lymphomas, neuroblastomas, malignant germ cell tumours andbrain tumours), with the aim of offering a personalized biological profile of the tumour in a particular patient. Ground-breaking research is also envisaged in neurosciences, especially in epilepsy, using PET tracers that would enable a better identification of the epileptogenic focus, and in psychiatry, with the use of radiolabeled neurotransmitters. In paediatric nephro-urology, the identification of the asymptomatic child with ante-natally diagnosed hydronephrosis at risk of losing renal parenchymal function if left untreated is another area of active research involving radionuclide renography.
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Affiliation(s)
- Lorenzo Biassoni
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Marina Easty
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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23
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Babu R, Chowdhary S. Controversies Regarding Management of Vesico-ureteric Reflux. Indian J Pediatr 2017; 84:540-544. [PMID: 28477320 DOI: 10.1007/s12098-017-2359-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/18/2017] [Indexed: 11/28/2022]
Abstract
The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.
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Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra University, Chennai, Tamil Nadu, India
| | - Sujit Chowdhary
- Department of Pediatric Urology, Indraprastha Apollo Hospitals, New Delhi, 110076, India.
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24
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Kawai S, Kanai T, Hyuga T, Nakamura S, Aoyagi J, Ito T, Saito T, Odaka J, Furukawa R, Aihara T, Nakai H. Top-down approach is possible strategy for predicting breakthrough fUTIs and renal scars in infants. Pediatr Int 2017; 59:781-785. [PMID: 28370971 DOI: 10.1111/ped.13279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/22/2017] [Accepted: 03/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute-phase technetium-99 m dimercaptosuccinic acid (DMSA) scintigraphy is recommended for initial imaging in children with febrile urinary tract infection (fUTI). Recently, the importance of identifying patients at risk of recurrent fUTI (r-fUTI) has been emphasized. To clarify the effectiveness of DMSA scintigraphy for predicting r-fUTI in infants, we investigated the relationship between defects on DMSA scintigraphy and r-fUTI. METHODS Seventy-nine consecutive infants (male: female, 60:19) with fUTI were enrolled in this study. DMSA scintigraphy was performed in the acute phase, and patients with defect underwent voiding cystourethrography and chronic-phase (6 months later) DMSA scintigraphy. Patients were followed on continuous antibiotic prophylaxis (CAP). RESULTS Defects on acute-phase DMSA scintigraphy were observed in 32 children (40.5%) of 79. The mean follow-up observation period was 17.0 ± 10.1 months. Four patients had r-fUTI (5%). Two of them had defects on DMSA scintigraphy in both the acute phase and chronic phase, and had bilateral vesicoureteral reflux (VUR) grade IV. Two others had r-fUTI without defects on DMSA and did not have VUR. Twelve patients had defect on chronic-phase DMSA scintigraphy and four of them had no VUR. CONCLUSIONS The top-down approach is a possible method for predicting r-fUTI in infants and does not miss clinically significant VUR. Also, given that the prevalence of r-fUTI was 5% regardless of the presence of defects on acute-phase DMSA, then, in conjunction with genital hygiene and CAP, acute-phase DMSA might be unnecessary if chronic-phase DMSA is performed for all patients to detect renal scar.
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Affiliation(s)
- Shina Kawai
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Takahiro Kanai
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Taiju Hyuga
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Shigeru Nakamura
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Jun Aoyagi
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Takane Ito
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Takashi Saito
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Jun Odaka
- Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Rieko Furukawa
- Department of Pediatric Radiology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Toshinori Aihara
- Department of Pediatric Radiology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Hideo Nakai
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
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25
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Abdelhalim A, Khoury AE. Critical appraisal of the top-down approach for vesicoureteral reflux. Investig Clin Urol 2017; 58:S14-S22. [PMID: 28612056 PMCID: PMC5468260 DOI: 10.4111/icu.2017.58.s1.s14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/14/2017] [Indexed: 11/18/2022] Open
Abstract
Vesicoureteral reflux (VUR) has been linked to recurrent urinary tract infections (UTIs), renal scarring, hypertension, renal insufficiency and end-stage kidney disease. Different imaging strategies have been proposed to approach children presenting with UTI to sort out patients with significant VUR while minimizing patient morbidity, radiation exposure and financial burden. None of these imaging strategies is universally accepted. The“top-down approach” (TDA) aims at restricting the number of voiding cystourethrograms (VCUGs) and its associated morbidity while identifying patients with clinically-significant reflux. In this approach, children presenting with febrile UTIs are acutely investigated with dimercapto-succinic acid (DMSA) renal scans to identify patients with renal parenchymal inflammation. Those with evidence of renal affection are offered VCUG and late DMSA scan to identify VUR and permanent renal scarring, respectively. Although TDA could identify clinically-significant VUR with high sensitivity, it is not without limitations. The approach segregates patients based on the presence of DMSA cortical lesions omitting the morbidity and the economic burden of UTI. Additionally, some of DMSA lesions are attributed to congenital dysplasia and unrelated to UTI. Ionizing radiation exposure, financial costs, limited availability of DMSA scans in the acute setting, variability in interpreting the results and low yield of actionable findings on DMSA scans are some other limitations. In this review, we tried to address the drawbacks of the TDA and reinforce the value of patient-centered approach for VUR.
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Affiliation(s)
- Ahmed Abdelhalim
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA.,Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Antoine E Khoury
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA
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Zeb A, Ullah F, Ayaz M, Ahmad S, Sadiq A. Demonstration of biological activities of extracts from Isodon rugosus Wall. Ex Benth: Separation and identification of bioactive phytoconstituents by GC-MS analysis in the ethyl acetate extract. Altern Ther Health Med 2017; 17:284. [PMID: 28558679 PMCID: PMC5450350 DOI: 10.1186/s12906-017-1798-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 05/17/2017] [Indexed: 12/02/2022]
Abstract
Background Since long, natural sources have been explored for possible managements of various diseases. In this context, the study is designed to evaluate Isodon rugosus Wall. ex Benth for biological potentials including antibacterial, anthelmintic, insecticidal, anti-termites and anti-Pharaoh activities followed by GC-MS analysis of active fraction to identify various bioactive compounds. Methods I. rugosus was investigated against eight bacterial strains using well diffusion method and microdilution method with ceftriaxone as positive control. Similarly, the insecticidal activity was carried out against Tribolium castaneum, Rhyzopertha dominica, Monomorium pharaonis and Heterotermis indicola following contact toxicity method. Likewise, anthelmintic activity was performed against Ascaridia galli and Pherethima posthuma using albendazole as positive control, in which the paralysis and death times of the worms were observed. The GC-MS analysis of the most active solvent fraction was performed for identifications of various bioactive compounds. Results Among the tested samples of I. rugosus, flavonoids and ethyl acetate fraction exhibited high antibacterial activities. The crude saponins showed highest anthelmintic activity against Pherethima posthuma and Ascaridia galli with death times of 27.67 and 29.22 min respectively at concentrations of 40 mg/ml. In insecticidal activity, chloroform fraction and saponins exhibited notable results against R. dominica (60 and 70%) and T. castaneum (70 and 76%) at concentration of 200 mg/ml. In anti-termite assay, all the plant samples showed overwhelming results, i.e. all the 25 termites were killed on the 3rd day. Similarly, in anti-Pharaoh activity, the chloroform, ethyl acetate and saponins fractions were most potent, each exhibiting LD50 of <0.1 mg/ml. In GC-MS analysis, total of 57 compounds were identified. Some of the bioactive compounds identified in GC-MS analysis are palmitic acid, hinokiol, α-amyrin, phytol, ethyl linolate, cyclohexanone, hinokione, methyl palmitate, ethyl palmitate and stigmasterol acetate. Conclusions Based on our current results, it can be concluded that I. rugosus possess strong antibacterial, insecticidal and anthelmintic potentials having crude saponins and ethyl acetate as the most active fractions. The GC-MS analysis and biological assays reveal that ethyl acetate fraction is a suitable target for the isolation of diverse array of bioactive compounds.
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Mendichovszky I, Solar BT, Smeulders N, Easty M, Biassoni L. Nuclear Medicine in Pediatric Nephro-Urology: An Overview. Semin Nucl Med 2017; 47:204-228. [PMID: 28417852 DOI: 10.1053/j.semnuclmed.2016.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the context of ante-natally diagnosed hydronephrosis, the vast majority of children with a dilated renal pelvis do not need any surgical treatment, as the dilatation resolves spontaneously with time. Slow drainage demonstrated at Tc-99m-mercaptoacetyltriglycine (MAG3) renography does not necessarily mean obstruction. Obstruction is defined as resistance to urinary outflow with urinary stasis at the level of the pelvic-ureteric junction (PUJ) which, if left untreated, will damage the kidney. Unfortunately this definition is retrospective and not clinically helpful. Therefore, the identification of the kidney at risk of losing function in an asymptomatic patient is a major research goal. In the context of renovascular hypertension a DMSA scan can be useful before and after revascularisation procedures (angioplasty or surgery) to assess for gain in kidney function. Renal calculi are increasingly frequent in children. Whilst the vast majority of patients with renal stones do not need functional imaging, DMSA scans with SPECT and a low dose limited CT can be very helpful in the case of complex renal calculi. Congenital renal anomalies such as duplex kidneys, horseshoe kidneys, crossed-fused kidneys and multi-cystic dysplastic kidneys greatly benefit from functional imaging to identify regional parenchymal function, thus directing further management. Positron emission tomography (PET) is being actively tested in genito-urinary malignancies. Encouraging initial reports suggest that F-18-fluorodeoxyglucose (FDG) PET is more sensitive than CT in the assessment of lymph nodal metastases in patients with genito-urinary sarcomas; an increased sensitivity in comparison to isotope bone scans for skeletal metastatic disease has also been reported. Further evaluation is necessary, especially with the promising advent of PET/MRI scanners. Nuclear Medicine in paediatric nephro-urology has stood the test of time and is opening up to new exciting developments.
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Affiliation(s)
- Iosif Mendichovszky
- Department of Radiology, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | | | - Naima Smeulders
- Department of Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marina Easty
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lorenzo Biassoni
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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Renal scarring in children under 36 months hospitalised for acute pyelonephritis. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Díaz Álvarez M, Acosta Batista B, Pérez Córdova R, Hernández Robledo E. [Urinary tract infection caused by Enterobacteriaceae and its relationship with vesicoureteral reflux]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2017; 74:34-40. [PMID: 29364812 DOI: 10.1016/j.bmhimx.2016.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/23/2016] [Accepted: 10/19/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The first urinary tract infection can be a marker of a urinary tract anomaly, mainly vesicoureteral reflux. The aim of this work was to determine the association between isolated enterobacteria with the presence and grade of vesicoureteral reflux in neonatal patients with their first urinary tract infection. METHODS A retrospective, observational and analytic study of newborns, who were admitted to the Neonatal Department, University Pediatric Hospital "Juan Manuel Márquez," in Havana, Cuba, from 1992 to 2013 was conducted. The causal microorganism of urinary tract infection was from the Enterobacteriaceae family. They were evaluated by radio imaging. The association between the presence and grade of vesicoureteral reflux with the causal microorganism of the urinary tract infection was analyzed. RESULTS Newborn infants with urinary tract infection (450) were studied. Bacterial isolations in the urine cultures corresponded to E. coli in 316 cases (70.2%). The prevalence of vesicoureteral reflux was 18.2%. The presence of bacteria corresponding to the Enterobacteriaceae family (other than E. coli) had significant risk association with vesicoureteral reflux (OR: 2.02; p < 0.01) and vesicoureteral reflux classification (for higher grades, p < 0.01). CONCLUSIONS E. coli is the most frequent causal microorganism in neonatal urinary tract infection. However, an association between the isolation of a microorganism of the Enterobacteriaceae family different to E. coli with the presence of vesicoureteral reflux and mainly with higher grades of vesicoureteral reflux exists.
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Affiliation(s)
- Manuel Díaz Álvarez
- Servicio de Neonatología, Hospital Pediátrico Universitario "Juan M. Márquez", La Habana, Cuba.
| | - Bárbara Acosta Batista
- Servicio de Neonatología, Hospital Pediátrico Universitario "Juan M. Márquez", La Habana, Cuba
| | - Rodolfo Pérez Córdova
- Servicio de Neonatología, Hospital Pediátrico Universitario "Juan M. Márquez", La Habana, Cuba
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Yel S, Tülpar S, Düşünsel R, Poyrazoğlu HM, Dursun İ, Abdülrezzak Ü, Gündüz Z, Yılmaz K, Baştuğ F. Voiding cystourethrogram: How much should we be selective? Turk J Urol 2017; 43:79-84. [PMID: 28270956 DOI: 10.5152/tud.2016.56750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 07/19/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In this study, we examined the patients' characteristics, who underwent voiding cystourethrography (VCUG), in order to determine any selectivity for indication of this invasive method. MATERIAL AND METHODS After exclusion of indications of neurogenic bladder or antenatal hydronephrosis and control VCUGs, 159 VCUGs performed in our clinic within one year were evaluated. Patients are divided into three groups accoding to age. Clinical characteristic and findings of renal ultrasonography (US) and renal scintigraphy were examined. RESULTS Vesicoureteral reflux (VUR) was detected in 61 (38.3%) of 159 patients who underwent cystourethrographic examinations, in 45.8% of the patients with a history of recurrent urinary tract infection (UTI), in 22.0% of the patients with pathological urinary system US without history of recurrent UTI. High-grade reflux rate was significantly more frequent in renal units with pathological US findings. Severe scar was significantly more frequent in renal units with high-grade reflux when compared to renal units without reflux and those with low-grade reflux. Predictive values of recurrent UTI, scarring status and pathological US for VUR were separately analyzed and seen that likelihood of indicating VUR was increased when all 3 risk factors were assessed together. CONCLUSION Vesicoureteral reflux is a problem in which diagnostic process and management strategy should have to be considered in individualized manner for each patient. Before prescribing invasive VCUG, imaging urinary system by US and scintigraphy and determining whether there is recurrent UTI will improve selectivity and success of VCUG.
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Affiliation(s)
- Sibel Yel
- Department of Pediatric Nephrology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Sebahat Tülpar
- Department of Pediatric Nephrology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Ruhan Düşünsel
- Department of Pediatric Nephrology, Erciyes University School of Medicine, Kayseri, Turkey
| | | | - İsmail Dursun
- Department of Pediatric Nephrology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Ümmühan Abdülrezzak
- Department of Nuclear Medicine, Erciyes University School of Medicine Kayseri, Turkey
| | - Zübeyde Gündüz
- Department of Pediatric Nephrology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Kenan Yılmaz
- Department of Pediatric Nephrology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Funda Baştuğ
- Department of Pediatric Nephrology, Erciyes University School of Medicine, Kayseri, Turkey
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Hua L, Linke RJ, Boucaut HAP, Khurana S. Micturating cystourethrogram as a tool for investigating UTI in children - An institutional audit. J Pediatr Urol 2016; 12:292.e1-292.e5. [PMID: 27230383 DOI: 10.1016/j.jpurol.2016.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 03/04/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Micturating cystourethrograms (MCUG) are the gold standard for evaluating vesicoureteric reflux (VUR). There is a growing consensus for increasing the threshold for performing MCUGs following urinary tract infections (UTI) in children. There are several varying guidelines. It is important to detect high-grade reflux in the setting of an UTI because of potential long-term complications. OBJECTIVE This audit aimed to retrospectively: (1) identify the conformance rate of local guidelines at the Women's and Children's Hospital (WCH); (2) assess predictors for an abnormal MCUG; and (3) compare local guidelines against the Royal Children's Hospital, Melbourne (RCH), National Institute for Healthcare and Excellence (NICE), and American Academy of Pediatrics (AAP) guidelines for selectively detecting high-grade reflux. METHOD The number of MCUGs performed from 2008 to 2012 at the WCH radiology department was collected. Patients undergoing MCUG during the 2012 calendar year were identified. Only children having an initial MCUG as part of an UTI investigation with prerequisite imaging as per guidelines were included. Each child's age, sex, referral source, reason, renal ultrasound (RUS) prior to the MCUG, MCUG result and VUR grade were recorded. The WCH guidelines were applied to determine conformance, to evaluate predictors for an abnormal MCUG, and compared against other retrospectively applied guidelines (RCH, NICE, AAP). RESULTS/DISCUSSION There was complete data for 168 children who underwent MCUG as part of an UTI investigation (median age 0.79 years, range 0.12-8.74, male:female 67:101). There were 67/168 abnormal MCUGs (62 children with VUR, five bladder diverticulum), and 97 refluxing renal units (43 high-grade VUR units). No posterior urethral valves (PUV) were identified as part of the UTI investigation. A total of 143/168 patients had prior RUS (normal:abnormal 67:76). The WCH guidelines had 82% conformance. There was no statistically significant association between an abnormal MCUG and age, sex, referral source, reason, or prior RUS result. The WCH guidelines may have missed five children with high-grade VUR (four children had surgery), compared with RCH, APP and NICE, with 8, 15, and 17 children, respectively, having high-grade VUR (two, five, and five children had surgery, respectively) show in the Summary Table. The retrospective study had limitations and possible selection bias (children with UTI without a MCUG). There were no standard treatment approaches for VUR; hence establishing a MCUG guideline is difficult. An alternative is the top-down approach. CONCLUSION Current institutional guidelines for considering MCUG following UTI in children vary considerably. The MCUG guidelines at any institution must take into account the local management guidelines for high-grade VUR.
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Affiliation(s)
- L Hua
- Department of Surgery, Central Adelaide Local Health Network, Adelaide, Australia.
| | - R J Linke
- Department of Medical Imaging, Women's and Children's Hospital, Adelaide, Australia
| | - H A P Boucaut
- Department of Paediatric Surgery and Urology, Women's and Children's Hospital, Adelaide, Australia
| | - S Khurana
- Department of Paediatric Surgery and Urology, Women's and Children's Hospital, Adelaide, Australia
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Abstract
Acute pyelonephritis is one of the most serious bacterial illnesses during childhood. Escherichia coli is responsible in most cases, however other organisms including Klebsiella, Enterococcus, Enterobacter, Proteus, and Pseudomonas species are being more frequently isolated. In infants, who are at major risk of complications such as sepsis and meningitis, symptoms are ambiguous and fever is not always useful in identifying those at high risk. A diagnosis of acute pyelonephritis is initially made on the basis of urinalysis; dipstick tests for nitrites and/or leukocyte esterase are the most accurate indicators of infection. Collecting a viable urine sample for urine culture using clean voided methods is feasible, even in young children. No gold standard antibiotic treatment exists. In children appearing well, oral therapy and outpatient care is possible. New guidelines suggest less aggressive imaging strategies after a first infection, reducing radiation exposure and costs. The efficacy of antibiotic prophylaxis in preventing recurrence is still a matter of debate and the risk of antibiotic resistance is a warning against its widespread use. Well-performed randomized controlled trials are required in order to better define both the imaging strategies and medical options aimed at preserving long-term renal function.
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Gordon ZN, McLeod DJ, Ching CB, Herz DB, Bates DG, Becknell B, Alpert SA. Uroepithelial thickening improves detection of vesicoureteral reflux in infants with prenatal hydronephrosis. J Pediatr Urol 2016; 12:257.e1-7. [PMID: 27342956 PMCID: PMC5532540 DOI: 10.1016/j.jpurol.2016.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/22/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Postnatal evaluation of prenatal hydronephrosis (PNH) often includes a voiding cystourethrogram (VCUG) for VUR assessment. Despite limited supporting data, VCUG is currently recommended if postnatal renal and bladder ultrasound (RBUS) reveals moderate/severe hydronephrosis (HN) or hydroureter (HU). Recent studies have shown VUR is more accurately diagnosed by using certain sonographic findings as criteria for obtaining VCUG. Uroepithelial thickening (UET) of the renal pelvis is a finding associated with high-grade vesicoureteral reflux (HGVUR); however, the clinical significance of UET with PNH has not been studied. OBJECTIVE We sought to determine if the presence of UET implies increased risk for VUR, and to investigate whether UET can improve the test characteristics of RBUS for VUR. STUDY DESIGN We retrospectively analyzed postnatal RBUS and VCUG findings in infants ≤30 days undergoing evaluation for "prenatal hydronephrosis" over an 11-year period. We used logistic regression to identify factors associated with VUR. Test characteristics of RBUS for HGVUR were compared based on the presence of UET and two criteria sets to define abnormal RBUS. Criteria set 1 consisted of HN SFU grade 3-4 and/or HU; criteria set 2 was defined by the presence of two of following: UET, HU, duplication, and/or renal dysmorphia. RESULTS Of 135 patients, 39 (29%) had VUR, of whom 16 (41%) had HGVUR. UET was significantly associated with VUR (p < 0.001), and the sensitivity for HGVUR based on UET alone was 94%. On multivariable analysis, UET, HU, duplication, and renal dysmorphia remained significant independent predictors of HGVUR. Compared to criteria 1, using criteria 2 resulted in 43 fewer VCUGs, and significant improvement in sensitivity and specificity for HGVUR (Table). DISCUSSION Consistent with previous studies, HN alone on postnatal RBUS has little value in predicting the presence or severity of VUR. This study is the largest known series to evaluate UET in the setting of PNH, and our results demonstrate that UET, as well as HU, duplication and renal dysmorphia, are independent sonographic findings predicting HGVUR. Using our proposed criteria, the probability of HGVUR is fourfold more than the prevalence described in the literature, and importantly, when compared to the criteria recommended by the SFU and AUA, would have resulted in 53% fewer VCUGs while missing zero cases of HGVUR. CONCLUSION In infants with PNH, the sonographic findings of UET, HU, duplication and renal dysmorphia independently indicate greater risk of HGVUR, and the sensitivity and specificity of RBUS for HGVUR is markedly improved when at least two of the four are present.
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Affiliation(s)
- Zachary N Gordon
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daryl J McLeod
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christina B Ching
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel B Herz
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - D Gregory Bates
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Becknell
- Section of Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Seth A Alpert
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
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Antimicrobial Resistance and Diagnostic Imaging in Infants Younger Than 2 Months Old Hospitalized With a First Febrile Urinary Tract Infection: A Population-based Comparative Study. Pediatr Infect Dis J 2016; 35:840-5. [PMID: 27100129 DOI: 10.1097/inf.0000000000001184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data on urinary tract infection (UTI) in infants ≤2 months of age are limited. We examined clinical characteristics, antimicrobial resistance, imaging findings and clinical outcomes in infants ≤2 months of age and children 2-24 months of age hospitalized with the first febrile UTI. METHODS Children ≤24 months of age hospitalized with their first-diagnosed febrile UTI were prospectively studied. Renal ultrasonography, Tc-dimercaptosuccinic acid scanning and voiding cystourethrography were performed in all children. RESULTS Of the 388 children analyzed (255 boys and 133 girls), 61 patients were ≤2 months of age, representing 15.7% of the whole population, whereas 327 patients were 2-24 months of age. Escherichia coli was the predominant bacterium, with similar antimicrobial resistance in the 2 groups, and associated E. coli bacteremia occurred in 9 patients (2.3%). Renal ultrasonography showed abnormal findings in 130 patients (33.5%), but there was no difference in the rate of abnormal findings between the groups. Vesicoureteral reflux (VUR) was present in 130 children (33.5%), including 93 (24%) with grades III-V VUR. VUR was more prevalent in the infants ≤2 months of age (P = 0.007), but there was no difference in the prevalence of grades III-V VUR between the groups. The incidence of renal scarring was 28.6% (111/388), and it did not differ between the groups. CONCLUSIONS There are similarities in clinical characteristics, antimicrobial resistance, imaging findings and clinical outcomes after a first UTI between the young infants ≤2 months and children 2-24 months of age. The same guidelines for the diagnosis and management after the first febrile UTI can be applied to children who are ≤24 months of age.
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Shaikh N, Spingarn RB, Hum SW. Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections. Cochrane Database Syst Rev 2016; 7:CD010657. [PMID: 27378557 PMCID: PMC6457894 DOI: 10.1002/14651858.cd010657.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is considerable interest in detecting vesicoureteral reflux (VUR) because its presence, especially when severe, has been linked to an increased risk of urinary tract infections and renal scarring. Voiding cystourethrography (VCUG), also known as micturating cystourethrography, is the gold standard for the diagnosis of VUR, and the grading of its severity. Because VCUG requires bladder catheterisation and exposes children to radiation, there has been a growing interest in other screening strategies that could identify at-risk children without the risks and discomfort associated with VCUG. OBJECTIVES The objective of this review is to evaluate the accuracy of two alternative imaging tests - the dimercaptosuccinic acid renal scan (DMSA) and renal-bladder ultrasound (RBUS) - in diagnosing VUR and high-grade VUR (Grade III-V VUR). SEARCH METHODS We searched MEDLINE, EMBASE, BIOSIS, and the Cochrane Register of Diagnostic Test Accuracy Studies from 1985 to 31 March 2016. The reference lists of relevant review articles were searched to identify additional studies not found through the electronic search. SELECTION CRITERIA We considered published cross-sectional or cohort studies that compared the results of the index tests (DMSA scan or RBUS) with the results of radiographic VCUG in children less than 19 years of age with a culture-confirmed urinary tract infection. DATA COLLECTION AND ANALYSIS Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate summary sensitivity and specificity values. MAIN RESULTS A total of 42 studies met our inclusion criteria. Twenty studies reported data on the test performance of RBUS in detecting VUR; the summary sensitivity and specificity estimates were 0.44 (95% CI 0.34 to 0.54) and 0.78 (95% CI 0.68 to 0.86), respectively. A total of 11 studies reported data on the test performance of RBUS in detecting high-grade VUR; the summary sensitivity and specificity estimates were 0.59 (95% CI 0.45 to 0.72) and 0.79 (95% CI 0.65 to 0.87), respectively. A total of 19 studies reported data on the test performance of DMSA in detecting VUR; the summary sensitivity and specificity estimates were 0.75 (95% CI 0.67 to 0.81) and 0.48 (95% CI 0.38 to 0.57), respectively. A total of 10 studies reported data on the accuracy of DMSA in detecting high-grade VUR. The summary sensitivity and specificity estimates were 0.93 (95% CI 0.77 to 0.98) and 0.44 (95% CI 0.33 to 0.56), respectively. AUTHORS' CONCLUSIONS Neither the renal ultrasound nor the DMSA scan is accurate enough to detect VUR (of all grades). Although a child with a negative DMSA test has an < 1% probability of having high-grade VUR, performing a screening DMSA will result in a large number of children falsely labelled as being at risk for high-grade VUR. Accordingly, the usefulness of the DMSA as a screening test for high-grade VUR should be questioned.
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Affiliation(s)
- Nader Shaikh
- Children's Hospital of PittsburghGeneral Academic Pediatrics3414 Fifth Ave, Suite 301PittsburghPAUSA15213
| | - Russell B Spingarn
- University of Pittsburgh School of Medicine3550 Terrace StreetPittsburghPAUSA15261
| | - Stephanie W Hum
- Children's Hospital of PittsburghGeneral Academic Pediatrics3414 Fifth Ave, Suite 301PittsburghPAUSA15213
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Rodríguez Azor B, Ramos Fernández JM, Sánchiz Cárdenas S, Cordón Martínez A, Carazo Gallego B, Moreno-Pérez D, Urda Cardona A. [Renal scarring in children under 36 months hospitalised for acute pyelonephritis]. An Pediatr (Barc) 2016; 86:76-80. [PMID: 27198883 DOI: 10.1016/j.anpedi.2016.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Acute pyelonephritis (APN) is one of the most common causes of serious bacterial infection in infants. Renal scarring is the most prevalent long-term complication. OBJECTIVES To review the incidence of renal scarring within 6 months after an episode of APN in children under 36 months and its relationship with imaging studies, clinical settings, and bacteriology. METHOD A retrospective study of previously healthy patients aged one to 36 months, admitted for a first episode of APN, with a minimum follow-up of 6 months. Demographic and clinical variables were collected along with bacteriology, renal and bladder ultrasound scan, voiding cystourethrography, DMSA-scintigraphy, and re-infection events. RESULTS A total of 125 patients were included in the study, of which 60% were male, the large majority (92%) febrile, and due to E. coli (74.6%). There was a history of prenatal ultrasound scan changes in 15.4%. Ultrasound scan found dilation of the urinary tract in 22.1%. Voiding cystourethrography was performed on 70 patients: 54.3% no abnormalities, 12.8% vesicoureteral reflux (VUR) grade i-iii, and 32.9% iv-v grade VUR. Six patients had iv-v grade VUR with a normal ultrasound scan. Adherence to DMSA-scintigraphy at 6 months was only 61% of that indicated. Renal scarring was found in 44.3% of those in which it was performed (60 cases). CONCLUSIONS Almost half (44%) DMSA-scintigraphy in children aged one to 36 months hospitalised for APN show renal scarring at 6 months, which was found to be associated with the re-infection events and the iv-v grade VUR. There was no relationship between scarring and the bacteriology or the elevations of inflammatory biochemical markers.
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Affiliation(s)
- Begoña Rodríguez Azor
- Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, España
| | - José Miguel Ramos Fernández
- Sección de Lactantes, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga; Grupo de Investigación IBIMA, Málaga, España.
| | - Sonia Sánchiz Cárdenas
- Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, España
| | - Ana Cordón Martínez
- Sección de Lactantes, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga
| | - Begoña Carazo Gallego
- Sección de Infectología, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario Materno-Infantil, Málaga, España
| | - David Moreno-Pérez
- Grupo de Investigación IBIMA, Málaga, España; Departamento de Pediatría y Farmacología, Facultad de Medicina, Universidad de Málaga, Málaga, España; Sección de Infectología, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario Materno-Infantil, Málaga, España
| | - Antonio Urda Cardona
- Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, España
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Wongbencharat K, Tongpenyai Y, Na-Rungsri K. Renal ultrasound and DMSA screening for high-grade vesicoureteral reflux. Pediatr Int 2016; 58:214-8. [PMID: 26275163 DOI: 10.1111/ped.12803] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/02/2015] [Accepted: 08/10/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Selection of the appropriate radiologic investigation in a child after first febrile urinary tract infection (UTI) remains a contentious issue. This report investigated the effectiveness of renal bladder ultrasound (RBUS) and late 6 month dimercaptosuccinic acid (DMSA) renal scan in the detection of high-grade vesicoureteral reflux (VUR) after first febrile UTI in infants aged <1 year. METHODS A total of 387 infants aged <1 year with first febrile UTI who completed diagnostic follow up consisting of RBUS, voiding cystourethrogram (VCUG) and late 6 month DMSA scan were enrolled in the study. The effectiveness of RBUS and DMSA scan in the detection of high-grade VUR, including cost and benefit were assessed. RESULTS Abnormal RBUS was identified in 95 infants (24.5%). VUR was identified on VCUG in 79 (20.4%), of whom eight (2.1%) had high-grade VUR (grade IV-V). Abnormal renal parenchyma was identified on late 6 month DMSA scan in 22 infants (5.7%). The sensitivity of abnormal RBUS and of late 6 month DMSA scan in the prediction of high-grade VUR was 50% and 87.5%, and the proportion of infants who avoided unnecessary VCUG was 75.5% and 94.3%, respectively. CONCLUSIONS Fifty percent of high-grade VUR was not identified on RBUS screening after first febrile UTI. Although late 6 month DMSA scan had higher sensitivity in the detection of high-grade VUR, with the added benefit of detection of renal scars, the practical application of this method was limited due to its high cost, radiation exposure and the associated delay in decision making.
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Gebäck C, Hansson S, Martinell J, Milsom I, Sandberg T, Jodal U. Obstetrical outcome in women with urinary tract infections in childhood. Acta Obstet Gynecol Scand 2016; 95:452-7. [PMID: 26970552 DOI: 10.1111/aogs.12853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Urinary tract infections (UTI) during childhood can result in permanent renal damage, with possible implications for future pregnancies. The aim of this prospective study was to investigate pregnancy outcomes in women followed after their first UTI in childhood. MATERIAL AND METHODS A cohort of 72 parous women was followed from their first UTI in childhood up to a median age of 41 years. Clinical data were obtained from antenatal and hospital records. Renal damage was evaluated by a (99m) Tc-dimercaptosuccinic acid scan. Pregnancy blood pressure (BP), complications and UTIs were compared between women with and without renal damage. RESULTS All women completed the investigations, 48 with and 24 without renal damage. No woman, irrespective of presence or absence of renal damage, was diagnosed with hypertension before the first pregnancy. Pregnancy-related hypertension was diagnosed in 10 of 151 pregnancies, all in women with renal damage. Preeclampsia occurred in four women. Women with renal damage had significantly higher systolic BP measured at the last antenatal visit of their first pregnancy, compared with women without renal damage (p = 0.005). During subsequent pregnancies both systolic and diastolic BP were significantly higher in women with than without renal damage (p = 0.02 and p = 0.03, respectively). CONCLUSION In this population-based follow-up study we found a large proportion of women with renal damage after UTI in childhood. Women with renal damage had significantly higher BP during pregnancy compared with women without renal damage. Pregnancy-related hypertension was recorded only in women with renal damage. However, pregnancy complications, including preeclampsia, were few.
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Affiliation(s)
- Carin Gebäck
- Department of Pediatrics, Institute of Clinical Sciences, Gothenburg, Sweden.,Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sverker Hansson
- Department of Pediatrics, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Jeanette Martinell
- Department of Pediatrics, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Ian Milsom
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Torsten Sandberg
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ulf Jodal
- Department of Pediatrics, Institute of Clinical Sciences, Gothenburg, Sweden
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Riccabona M. Imaging in childhood urinary tract infection. Radiol Med 2015; 121:391-401. [DOI: 10.1007/s11547-015-0594-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/08/2015] [Indexed: 10/22/2022]
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Demir S, Tokmak N, Cengiz N, Noyan A. Value of sonographic anterior-posterior renal pelvis measurements before and after voiding for predicting vesicoureteral reflux in children. JOURNAL OF CLINICAL ULTRASOUND : JCU 2015; 43:490-494. [PMID: 25545034 DOI: 10.1002/jcu.22260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 10/03/2014] [Accepted: 11/16/2014] [Indexed: 06/04/2023]
Abstract
PURPOSE Voiding cystourethrography (VCUG) is the gold standard for diagnosing vesicoureteral reflux (VUR), but it is important to minimize the use of VCUG because of the urinary catheterization and radiation exposure required. Ultrasound (US) observations suggest that pelvicalyceal dilatation varies according to the degree of bladder fullness in children with urinary tract infection. The aim of this study was to assess whether anterior-posterior (AP) measurements of the renal pelvis on US before and after voiding can be used as a screening tool while predicting the presence of VUR in children. METHODS The subjects were toilet-trained children older than 4 years who required VCUG. Two groups were established based on the VCUG results: a VUR group of 40 kidney units (each unit defined as calyces and ureter) that exhibited different severities of reflux, and a control group of 68 kidney units unaffected by VUR. Prior to VCUG, US AP measurements of the renal pelvis of each kidney unit were recorded when the urinary bladder was full and again after bladder emptying. The change in AP measurement from before to after voiding was compared between the two groups. RESULTS The mean change in AP measurements from before to after voiding in the VUR group was significantly greater than that in the control group (p = 0.003). CONCLUSIONS Comparing US AP measurements of the renal pelvis before and after voiding is useful for identifying children who are suspected to have VUR and thus require immediate VCUG.
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Affiliation(s)
- Senay Demir
- Baskent University Faculty of Medicine, Radiology, Adana, Turkey
| | - Naime Tokmak
- Baskent University Faculty of Medicine, Radiology, Adana, Turkey
| | - Nurcan Cengiz
- Baskent University Faculty of Medicine, Pediatric Nephrology, Adana, Turkey
| | - Aytul Noyan
- Baskent University Faculty of Medicine, Pediatric Nephrology, Adana, Turkey
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Renal function in adult women with urinary tract infection in childhood. Pediatr Nephrol 2015; 30:1493-9. [PMID: 25814208 DOI: 10.1007/s00467-015-3084-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/01/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The risk of deterioration of renal function in patients with urinary tract infection (UTI)-associated renal damage over several decades is incompletely known but of importance in regard to follow-up. METHODS A population-based cohort of women followed from their first UTI in childhood was studied at median age of 27 years and now at 41 years. Renal damage was evaluated by (99m)Tc-dimercaptosuccinic acid scan and glomerular filtration rate (GFR) by (51)Cr-edetic acid clearance. Extent of individual kidney damage was graded as class 1 to 3. RESULTS Eighty-six women completed the investigation, 58 with renal damage, and 28 without. Of those with damage, one had chronic kidney disease (CKD) stage 3, 14 stage 2, and 43 stage 1. Women with bilateral damage had lower GFR than those with no or unilateral damage (p < 0.0001). Women with class 3 damage had numerically but not significantly lower GFR than the others with damage (p = 0.07). Between the two studies there was significant decrease of GFR in the group with bilateral damage (p = 0.01). CONCLUSIONS Women with UTI-associated renal damage had remarkably well preserved renal function, but those with bilateral or severe individual kidney damage may be considered for regular monitoring of GFR and blood pressure.
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Gordon ZN, McLeod DJ, Becknell B, Bates DG, Alpert SA. Uroepithelial Thickening on Sonography Improves Detection of Vesicoureteral Reflux in Children with First Febrile Urinary Tract Infection. J Urol 2015; 194:1074-9. [PMID: 25963184 DOI: 10.1016/j.juro.2015.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The 2011 American Academy of Pediatrics clinical practice guideline for childhood febrile urinary tract infection recommends voiding cystourethrography if renal and bladder ultrasound reveals hydronephrosis, scarring or "other findings" that suggest high grade vesicoureteral reflux. We sought to determine if the finding of uroepithelial thickening indicates greater risk of high grade vesicoureteral reflux and whether uroepithelial thickening improves the screening value of renal and bladder ultrasound. MATERIALS AND METHODS We retrospectively analyzed renal and bladder ultrasound and voiding cystourethrogram findings in children 2 to 24 months old with first febrile urinary tract infection during an 11-year period. Patients with uroepithelial thickening were compared to an age and gender matched sample without uroepithelial thickening. Logistic regression was used to identify factors associated with high grade vesicoureteral reflux. Test characteristics of renal and bladder ultrasound for high grade reflux were compared based on different criteria to define an abnormal renal and bladder ultrasound. RESULTS Of 226 patients 143 (63%) had vesicoureteral reflux, of whom 37 (26%) had high grade reflux. On multivariable analysis uroepithelial thickening was a significant independent predictor of high grade vesicoureteral reflux (OR 5.41, 95% CI 1.74-16.79, p = 0.004). When hydronephrosis and hydroureter were considered the only abnormal renal and bladder ultrasound findings warranting voiding cystourethrography, sensitivity of renal and bladder ultrasound for high grade reflux was 84%, and 6 children with high grade and 82 with low grade reflux would have been missed. When uroepithelial thickening was also considered an abnormal finding, the sensitivity increased to 97%, and only 1 child with high grade and 57 with low grade reflux would have been missed. CONCLUSIONS Uroepithelial thickening is associated with an increased risk of high grade vesicoureteral reflux and is an abnormal finding warranting voiding cystourethrography. Sensitivity of renal and bladder ultrasound as a screening test for high grade vesicoureteral reflux is markedly improved when uroepithelial thickening is considered.
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Affiliation(s)
- Zachary N Gordon
- Department of Urology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Daryl J McLeod
- Department of Urology, Ohio State University Wexner Medical Center, Columbus, Ohio; Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, Ohio
| | - Brian Becknell
- Section of Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - D Gregory Bates
- Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Seth A Alpert
- Department of Urology, Ohio State University Wexner Medical Center, Columbus, Ohio; Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, Ohio.
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Bocquet N, Biebuyck N, Lortat Jacob S, Aigrain Y, Salomon R, Chéron G. Explorations morphologiques après un premier épisode de pyélonéphrite chez l’enfant. Arch Pediatr 2015; 22:547-53. [DOI: 10.1016/j.arcped.2015.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 11/12/2014] [Accepted: 02/03/2015] [Indexed: 10/23/2022]
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Neues zu Harnwegsinfektionen bei Kindern. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-014-3225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ristola MT, Hurme T. Consequences of following the new American Academy of Pediatrics guidelines for imaging children with urinary tract infection. Scand J Urol 2015; 49:419-23. [PMID: 25660228 DOI: 10.3109/21681805.2015.1009485] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Urinary tract infections (UTIs) and vesicoureteral reflux (VUR) are assumed to predispose children to renal damage. Awareness of the significance of VUR and the possibility of reducing UTI recurrence and renal damage has warranted guidelines on which patients should undergo imaging after UTI. An authoritative guideline has been issued by the American Academy of Pediatrics (AAP). This study assessed the applicability of the AAP guidelines to a subpopulation of patients with UTI, 2-24-month-old children with febrile UTI. MATERIALS AND METHODS The records of 394 children aged 2-24 months with their first UTI were reviewed. Data were recorded on the indications for renal and bladder ultrasonography (RBUS) and voiding cystourethrography (VCUG) according to the AAP guidelines, RBUS results, VCUG results, use of antimicrobial prophylaxis, antireflux procedures and other urological treatment, and UTI recurrence. RESULTS An indication for RBUS was seen in 344 patients. RBUS results were abnormal in 87, including 53 with urinary tract dilatation. An unnecessary RBUS would have been avoided in 43 patients. Seven patients with an abnormal RBUS would not have undergone RBUS. An indication for VCUG was seen in 126 patients. VCUG was performed in 206 patients; VUR was found in 72 patients, including 36 with high-grade VUR. An unnecessary VCUG would have been avoided in 82 patients. High-grade VUR would have been missed in six patients. Five patients would not have undergone surgery. CONCLUSION The AAP guidelines for imaging studies in children aged 2-24 months with febrile UTI seem applicable to clinical practice.
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Affiliation(s)
| | - Timo Hurme
- b 2 Department of Pediatric Surgery, Turku University Hospital , Turku, Finland
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Abstract
Vesicoureteric reflux is defined as the retrograde passage of urine from the bladder into one or both ureters and often up to the kidneys, and mainly affects babies and infants. In severe cases dilatation of the ureter, renal pelvis, and calyces might be seen. Traditionally it was thought that only a low percentage of children have vesicoureteric reflux, but studies have suggested as many as 25-40% are affected. Guidelines recommend that the number of investigations for vesicoureteric reflux in children who have had a febrile urinary tract infection be reduced, but this approach is controversial. The recommendations also suggest that prophylactic antibiotics and surgery should be avoided in children with non-severe vesicoureteric reflux. In this Seminar I present data on the management of children with vesicoureteric reflux and give suggestions on how to navigate this difficult area.
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Affiliation(s)
- Kjell Tullus
- Department of Nephrology, Great Ormond Street Hospital for Children, London, UK.
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Awais M, Rehman A, Zaman MU, Nadeem N. Recurrent urinary tract infections in young children: role of DMSA scintigraphy in detecting vesicoureteric reflux. Pediatr Radiol 2015; 45:62-8. [PMID: 24993242 DOI: 10.1007/s00247-014-3062-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 04/29/2014] [Accepted: 05/21/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Performing micturiting cystourethrography (MCUG) in young children with recurrent urinary tract infections is controversial with discrepancy among the major guidelines. OBJECTIVE Previous studies have shown that a normal dimercaptosuccinic acid (DMSA) scintigraphy may avoid the need of performing MCUG for detecting vesicoureteric reflux in children with first febrile urinary tract infection. However, the role of DMSA for ruling out vesicoureteric reflux in children with recurrent urinary tract infections has not been studied. MATERIALS AND METHODS Approval from institutional ethical review committee was sought and the requirement of informed consent was waived. A total of 50 children under the age of 10 years with recurrent urinary tract infections underwent MCUG scan within 3 months of DMSA scan from January 2011 to September 2012 at our institution. Diagnosis of recurrent urinary tract infections and grading of vesicoureteric reflux was according to previously established standards. Abnormalities on DMSA scan - scarring, hydronephrosis and reduced differential renal function - were compared with presence of vesicoureteric reflux on MCUG. RESULTS High-grade vesicoureteric reflux was noted on MCUG in 22 (44%) cases. The findings on DMSA included hydronephrosis and scarring in 25 (50%) and 25 (50%) cases, respectively. Abnormalities on DMSA scan for detecting the presence of high-grade vesicoureteric reflux on MCUG examination had sensitivity, specificity, positive and negative predictive values of 95.45%, 35.71%, 53.85% and 90.91%, respectively. The positive and negative likelihood ratios were 1.48 and 0.13 respectively. CONCLUSION DMSA scan had high overall sensitivity and negative predictive value with a low negative likelihood ratio for ruling out high-grade vesicoureteric reflux on MCUG, which may obviate the need of invasive MCUG along with its associated drawbacks.
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Affiliation(s)
- Muhammad Awais
- Department of Radiology, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan,
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Awais M, Rehman A, Baloch NUA, Khan F, Khan N. Evaluation and management of recurrent urinary tract infections in children: state of the art. Expert Rev Anti Infect Ther 2014; 13:209-31. [PMID: 25488064 DOI: 10.1586/14787210.2015.991717] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.
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Affiliation(s)
- Muhammad Awais
- Department of Radiology, Aga Khan University Hospital, P.O. box 3500, Stadium Road, Karachi 74800, Sindh, Pakistan
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Telli O, Mermerkaya M, Hajiyev P, Aydogdu O, Afandiyev F, Suer E, Soygur T, Burgu B. Is top-down vs bottom-up radiological evaluation after febrile urinary tract infection really less stressful for the child and family? Challenging the dogma. J Urol 2014; 193:958-62. [PMID: 25444953 DOI: 10.1016/j.juro.2014.10.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE We evaluated whether stress levels in children and parents during radiological evaluation after febrile urinary tract infection are really lower using the top-down approach, where (99m)technetium dimercaptosuccinic acid renal scintigraphy is used initially, than the bottom-up approach, where voiding cystourethrography is initially performed and repeated examinations are easier for all. MATERIALS AND METHODS We prospectively evaluated 120 children 3 to 8 years old. Pain ratings were obtained using the Faces Pain Scale-Revised, and conversation during the procedure was evaluated using the Child-Adult Medical Procedure Interaction Scale-Revised by 2 independent observers. To evaluate parental anxiety, the State-Trait Anxiety Inventory form was also completed. Following a documented febrile urinary tract infection children were randomized to the top-down or bottom-up group. A third group of 44 children undergoing repeat voiding cystourethrography and their parents were also evaluated. RESULTS Child ratings of pain using the Faces Pain Scale-Revised were not significantly different between the top-down group following (99m)technetium dimercaptosuccinic acid renal scintigraphy (2.99 on a scale of 10) and the bottom-up group following voiding cystourethrography (3.21). Also the Faces Pain Scale-Revised was not significantly different in the repeat voiding cystourethrography group (3.35). On the Child-Adult Medical Procedure Interaction Scale-Revised there was negative correlation between child coping and child distress, as well as rate of child distress and adult coping promoting behavior. Parental state anxiety scores were significantly less in the top-down and repeat voiding cystourethrography groups than in the bottom-up group. CONCLUSIONS Although the top-down approach and repeat voiding cystourethrography cause less anxiety for caregivers, these values do not correlate to pain scale in children. This finding might be due to lack of appropriate evaluation tools of pediatric pain and anxiety. However, the theory that the top-down approach is less invasive, and thus less stressful, requires further research. The Child-Adult Medical Procedure Interaction Scale-Revised data indicate that influences in adult-child interaction are bidirectional.
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Affiliation(s)
- Onur Telli
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey.
| | - Murat Mermerkaya
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Perviz Hajiyev
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Ozgu Aydogdu
- Urology Clinic, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Faraj Afandiyev
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Evren Suer
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Tarkan Soygur
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
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Shih BF, Tsai JD, Tsao CH, Huang FY. Reappraisal of the effectiveness of 99mTc-dimercaptosuccinic acid scans for selective voiding cystourethrography in children with a first febrile urinary tract infection. Kaohsiung J Med Sci 2014; 30:608-12. [DOI: 10.1016/j.kjms.2014.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 10/05/2014] [Accepted: 10/13/2014] [Indexed: 11/30/2022] Open
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